Hybrid submental flaps for reconstruction in the head and neck: Part pedicled, part free

The Submental Artery Island Flap for Reconstruction of Acquired Maxillary and Palatal Defects After Tumor Ablation: Reversed Flow Versus the Extended Antegrade Design

BACKGROUND

The submental artery island flap (SIF) is a valid option for palatal reconstruction. However, the main limitation for its application for palatal defects is the arc of rotation. A novel modification for tunneling of the antegrade design of SIF that allows a compliant easy reach to the defect is described.

METHODS

Eighteen patients with Brown class II maxillectomy defects were included. Reconstruction started using reversed flow SIF in five patients then shifted to the modified antegrade technique in the remaining patients. Speech, swallowing, chewing, other parameters, and oncological outcomes were assessed.

RESULTS

The reversed flow group has high complications. In the antegrade SIF group, all flaps survived. One developed marginal flap necrosis that healed spontaneously. The follow-up period ranged from 1 to 4.2 years with favorable functional outcome and with no evidence of recurrence.

CONCLUSION

The modified SIF antegrade design is a reliable option for palate reconstruction that allows favorable functional and oncological outcome.

Are Submental Flap Reconstructions From Oncological and Reconstructive Perspective Safe? Evaluation and Review of Ipsilateral and Contralateral Submental Flap Reconstructions

This study compared the risk of nodal metastasis progression in the submandibular area when using submental flap contralateral (SFC) or submental flap ipsilateral (SFI) relative to the tumor side. Thirty patients underwent treatment for squamous cell carcinoma of the oral cavity. Submental flap ipsilateral and SFC were used in 14 and 16 patients, respectively. After unilateral supraomohyoid neck dissection (levels I-III), the SFC group showed a significantly higher total number of positive lymph nodes removed (P = 0.014). In addition, the number of positive lymph nodes in the IB region was significantly higher in the SFC group compared with the SFI group (P = 0.001). Tumour relapse was the same in both groups (SFI: n = 4/SFC: n = 4). The authors' results suggest that SFC can be adequately used to reconstruct oral cavity defects because, after rerouting, the rotation arc reaches the upper incisors and covers the arc of SFI rotation in the oral cavity. Moreover, with SFC, a complete neck block dissection and more radical tumor resection can be achieved without limitations.

An Innovative Methodology: The Submental Island Flap Offers Enhanced Soft Tissue Coverage to the Vascularized Iliac Crest Flap

The vascularized iliac crest flap has garnered widespread acclaim within the field of mandibular reconstruction attributable to its sufficient bone mass and congruent curved morphology. However, when the precise orientation of the iliac crest is imperative during mandibular reconstruction and there exists an accompanying defect within the oral soft tissue, the indispensability of an additional flap to facilitate concurrent defect repair becomes evident. In such instances, the submental island flap emerges as an exemplary candidate.

Submental Artery Island Flaps (SAIF) for Oral Cavity Cancer: Surgical Technique and Tertiary Care Experience

In oral cancer surgeries, oncological outcomes take precious driverseat. But the copassengers like reconstruction, cosmesis, swallowing and speech outcomes deserve equivalent importance. Submental Artery Island Flaps (SAIF) provide an underutilized and extremely versatile option for reconstruction of defects following early stage oral cavity tumour resections. In this prospective observational analysis, we describe the technique, challenges and outcomes of SAIF at our tertiary care institute. Sixteen patients with Stage I and II oral cavity cancers were enrolled between June 2020 to May 2021. Verrucous carcinomas were five and well differentiated carcinomas were 11 patients. After tumour excision and neck dissections, defects were reconstructed with Pedicled submental flaps. Complications and functional outcomes were analyzed over two years. Nineteen percent were ladies and 81% were gentlemen. Median age was 52 years. Tongue tumours formed majority with 56% cases. Largest skin paddle taken was 36 cm2. Flap survival was 88%. There were variations in venous drainage of flaps which have been depicted in case figures. There was no report of orocutaneous fistula. Grade 3-4 speech satisfaction was achieved by 81.2% patients at 6 months. Swallowing was excellent, grade 4-5 for 100% of patients at 6 months. One patient had distant metastasis at 7 months and died. SRLR (Submental flap Recurrences) and trismus were zero percent at two years. The unexplored field of submental flaps can be used for oral cancer reconstructions in a versatile way. Donor site easy closures, no scars on face, early resumption of daily activities and short hospital stay makes it one of the ideal options in early stage oral cavity defects.

Lateral Skull Base and Auricular Reconstruction

Reconstruction of the lateral temporal bone with adequate functional and cosmetic outcomes depends on a multidisciplinary approach including the head and neck surgeon, reconstructive surgeon, neurotologist, and anaplastologist. Approaching the defect includes consideration of the location, tissue type, function, and patient/tumor characteristics. Anatomic limitations due to prior therapy also play an important role in reconstructive choices. Here, we review contemporary literature regarding the reconstruction of this complex region.

Regional Flap Donor Sites in Head and Neck Reconstruction

Regional flaps are vital to head and neck reconstruction, allowing surgeons to harvest numerous reliable flaps without the need for microvascular anastomosis. These flaps are very useful in cases of vascular depletion and may prove superior to free flaps as a primary option in certain circumstances. Numerous harvest options are available, and the described harvest techniques are safe and straightforward for an experienced reconstructive surgeon to learn. Donor site morbidity is variable depending on flap selection but minimal in many cases. Regional flaps are an excellent option in resource-limited settings or when minimizing reoperation is a high priority.

Regional pedicled flap salvage options for large head and neck defects: The old, the new, and the forgotten

Objectives

The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting.

Methods

Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options.

Results

Specific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap.

Conclusions

Regional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations.

Introducing the thin and ultrathin submental artery perforator flaps for precise reconstruction following T1-2 oral cavity cancer resection

We reported a case series of thin (n = 32) and ultrathin (n = 4) submental artery perforator flaps (SMAPF) for precise reconstruction following T1-2 oral cavity cancer resection. The former is indicated for tongue reconstruction involving the tongue tip, and buccal lining replacement involving the mouth corner, while the latter is specifically tailored to restore superficial buccal defects after resection of small early cancer originating from oral submucous fibrosis. All flaps survived. Most flap reconstructions reached satisfactory cosmetic results. Based on this series, we discussed the indications of thin and ultrathin SMAPFs in intaoral reconstruction, and surgical tips for flap thinning.

Reconstruction of lower and midfacial soft tissue defects with a submental island flap

This study aims to analyze the feasibility and utility of a submental island flap and to identify whether this flap procedure is a good choice for the reconstruction of lower and midfacial soft-tissue defects. This was a retrospective study that included 12 patients with lower and midfacial soft tissue defects, which were reconstructed using the submental island flap technique. The medical records of 12 patients who underwent reconstruction with submental island flaps from September 2015 to September 2020 were reviewed and included 11 patients with skin cancer and 1 patient with a history of trauma. The mean age of the patients was 64.9 years. The details of the flap harvest were studied for flap size, the procedure to elevate the flap, pedicle flow, and flap survival rate. In addition, information on demographics, histology, location, size, recurrence, and outcomes was recorded. All of the flaps survived. The skin paddle size ranged from 22 to 55 cm² (mean size 33 cm²). Ten flaps were anterograde pedicle flaps and two flaps were retrograde pedicle flaps. All donor sites were closed using primary closure without any difficulty in neck movement. None of the patients had symptoms of postoperative facial palsy. There were no signs of any local or regional cancer recurrence. The mean follow-up time was 22.9 months. There was an esthetic appearance of graft sites. The submental island flap is a feasible and reliable option for the reconstruction of lower and midfacial defects, which provides good cosmetic results.

The submental island flap in head and neck reconstruction: A 10-year experience examining application, oncologic safety, and role of comorbidity

Background

We present our experience on reconstructive versatility and risk of nodal transfer with the submental island flap (SIF). We also examine the role of comorbidity as a predictor of complications.

Methods

Retrospective cohort study of patients undergoing SIF over 10-year period. Comorbidity determined using Adult Comorbidity Evaluation 27 index (ACE-27). Univariable/multivariable logistic regressions performed to determine association of these characteristics and rates of major complications.

Results

Fifty-eight patients underwent SIF reconstruction, 27 (45%) patients had moderate/severe comorbidity, and 24 (41%) experienced major complication. Multivariable analysis identified ACE-27 scores >2 predictive of major flap complications (OR: 17.38, 95% CI: 1.96-153.74, p = .01) and medical complications (OR: 5.8, 95% CI: 1.11-30.23, p = .037). There were no cases of pathologic nodal transfer.

Conclusion

The SIF is a versatile flap and oncologically safe in carefully selected patients. The ACE-27 index is strongly predictive of major postoperative complications.

Level of Evidence

4.

Mucosal Melanoma of the Hard Palate: Surgical Treatment and Reconstruction

Mucosal melanomas of the head and neck region are uncommon pathologies that can affect the oral cavity, and are characterized by a high rate of mortality. Considering the lack of knowledge regarding risk and prognostic factors, current best clinical practice is represented by a large surgical excision with disease-free margins, eventually associated with a reconstructive flap. Indeed, given the frequent necessity of postoperative radiotherapy and fast healing process, a reconstruction of the surgical gap is advisable. Even if several flaps have been most commonly used, the submental island flap represents a valid alternative thanks to local advantages and similar oncologic outcomes compared to free flaps.

Surgical anatomy of the submental artery perforator flap and assessment for application in postoperative reconstruction following oral cancer surgery: a prospective clinical study

The submental artery perforator flap (SMAPF) has an elongated pedicle, allowing good cosmetic outcomes to be achieved following oral reconstruction surgery. The improper dissection of perforators often leads to a vascular flap crisis. To avoid this, some surgeons choose to carry amounts of connective tissue around the pedicle. However the inclusion of connective tissue on the pedicle raises concerns about oncological safety. A surgical anatomical study of the submental vessel patterns and subdivisions of the cervical level I lymph nodes was conducted on 33 patients with primary oral cancer who underwent reconstruction with a SMAPF after tumour resection. The variations in vessels and cervical level I lymph nodes observed during SMAPF harvesting were recorded and analyzed. Two patterns of submental artery perforators and three patterns of submental veins were identified. The different characteristics of the lymph node distribution were elucidated for five subdivisions. All SMAPFs survived (n=33, 100%); however, two SMAPFs exhibited partial losses. The 3-year survival rate of patients was 84.5±6.4%, and there were no suspected flap-related recurrences. With detailed anatomical information on the vascular system and lymph node subdivision, SMAPFs are a reliable choice for postoperative reconstruction following oral cancer surgery, meeting the standards for oncological safety.

Assessment of surgical outcomes and oncological safety for submental artery perforator flap reconstruction after ablation of oral cancer

The submental artery perforator flap (SAPF) has been a new option for the intraoral reconstruction of oral squamous cell carcinoma (OSCC) patients in recent years, but its surgical outcomes have not been well assessed. We compared the surgical outcomes and oncological safety of SAPF reconstruction for medium-sized soft-tissue defects after the ablation of primary oral cancer with traditional submental island flaps (SIF) and anterolateral thigh perforator flaps (ALTPF). Fifty-one SAPFs, 30 SIF, and 74 ALTPF were reviewed for the intraoral medium-sized reconstructions after the ablation of oral cancer from our institutional clinical oncological databases. We performed comparative assessments on the variables of surgical outcome and oncological safety among the 3 cohorts. A Kaplan-Meier estimate of survival for each flap was calculated. Operating time was significantly reduced in the SIF and SAPF groups than ALTPF (p = 0.021 and 0.014, respectively). Flap thickness of SAPF was the significantly thinnest (mean 0.5 cm) among three groups. The common complications of donor site for both SAPF and SIF group were incision dehiscence and orocutaneous fistula. There was no significant difference in disease-free survival (DFS) among the 3 groups. However, several OSCC patients with the SIF reconstruction were found to have recurrences with a metastatic lymph node under the flap after the first operation. SAPF could be a versatile choice of the intraoral reconstruction for the medium-sized soft-tissue defects after the ablation of oral cancer.

Submental flap for reconstruction of anterior skull base, orbital, and high facial defects

PURPOSE

Large anterior skull base, orbital, and high facial defects can present a challenging reconstructive problem. Limited data exists in the literature on the use of a submental flap for reconstructing such defects. We aimed to describe the feasibility, success, and advantages of using variations of the submental flap for reconstruction of anterior skull base, orbital, and high facial defects.

MATERIALS & METHODS

Outcomes measured included flap method, flap survival, flap size, reconstructive site complications, donor site complications, and length of hospital stay.

RESULTS

Nine patients were identified that underwent submental flap reconstruction of anterior skull base, orbital, or high facial soft tissue defects. There were 5 pedicled, 2 hybridized, and 2 free submental flap reconstructions. Flap survival was 100%. One flap required leech therapy for early post-operative venous congestion. Average flap skin paddle size was 63.7 cm². Average length of hospital stay was 7.3 days. No complications from the donor site were reported.

CONCLUSIONS

Different variations on the submental flap are viable options for reconstruction of high defects in the head and neck. Such flaps have a number of unique qualities that are suitable for reconstruction of anterior skull base, orbital, and high facial defects.

Submental artery island flap with simultaneous level I neck dissection

BACKGROUND

The purpose of this study was to illustrate the submental island flap elevation technique with simultaneous level I neck dissection followed by the inset and reconstruction of an oropharyngeal defect.

METHODS

A 63-year-old patient with a T2N1M0 human papillomavirus-positive squamous cell carcinoma of the tonsil was treated with concurrent chemoradiotherapy (cisplatin + 66 Gy). A local recurrence 2.5 years after treatment was treated surgically and reconstructed with a submental island flap.

RESULTS

There were no complications and oral diet was initiated at 2 weeks and the gastrostomy tube was removed 1 month postoperatively. A video demonstration of the submental island flap elevation is included with a focus on how levels 1A and 1B can be dissected safely and this can be viewed online on Head & Neck's home page at http://onlinelibrary.wiley.com/.

CONCLUSION

The submental island flap can be performed safely with a level I neck dissection for head and neck reconstruction.

Reconstruction of intraoral defects after resection of cancer with two types of submental artery perforator flaps

The submental island flap is a common choice for reconstruction of intraoral defects. To obtain a thinner, more pliable flap and get a better oncological result, the submental artery perforator flap has been proposed, and to assess its feasibility for closure of defects after resection of cancers of the oral cavity we studied 20 patients, each of whom was treated in this way. All the flaps were classified into those with septocutaneous perforators (n=16) and those with musculocutaneous perforators (n=4), and the main veins that drained the flaps were two submental veins (n=17). There were two patterns of venous drainage: in pattern 1 (n=9) the external jugular vein provided the primary venous drainage, and in pattern 2, the submental veins drained mainly into the facial vein, the common facial vein, and the internal jugular (n=10). In one patient the submental veins bypassed the facial vein to drain into the internal jugular. Eighteen of the 20 patients had no postoperative complications. The remaining two developed mild venous congestion of the flaps, which was resolved with conservative management and no skin loss. No local or regional recurrence was detected after a mean (range) follow-up of 21 (4-35) months. This is a simple, reliable flap that can be used for the reconstruction of intraoral defects after resections for cancer, but its oncological outcome still requires proof in long-term, large-scale, clinical trials.

Vascular anatomy is a determining factor of successful submental flap raising: a retrospective study of 70 clinical cases

The vascular anatomy of submental flaps (SFs) represents a determining factor in successful SF raising. However, little attention has been focused on the venous return of SFs. Thus, the present study aimed to investigate SF venous return. This study enrolled patients who underwent SF reconstructive surgery in a tertiary referral center between November 2009 and October 2016. The drainage pathway of the SF venous return was routinely identified during the course of our operations to prevent damage during head and neck surgery. The venous return data of 70 patients were reviewed. The size of the flaps ranged from 15 to 84 cm², and total flap loss was not observed in the case series. All of the submental arteries originated from the facial artery; however, the submental veins of 70 patients returned to either the internal jugular vein (IJV, 72.9%) or the external jugular vein (EJV, 27.1%). Our data suggest that drainage of the submental vein into the EJV, which has been previously overlooked, should receive greater attention during SF surgeries. The results support mandatory preservation of the EJV and IJV and indicate that vascular anatomy is a determining factor for successful SF raising.

The use of the submental island flap in reconstructing palatal and facial defects in a surgical camp in East Africa

BACKGROUND

The goals of successful reconstructive surgery are to restore function and cosmesis; however, limitation of resources can become an important consideration in low-middle income countries.

METHODS

We describe our experience using the submental island flap in two cases during a short-term surgical camp in East Africa.

RESULTS

The submental island flap was utilized as an excellent alternative to a free flap to reconstruct a subtotal maxillectomy and a parotidectomy defect in two patients.

CONCLUSIONS

We demonstrate the successful use of this flap and describe some necessary modifications to achieve optimal results in a resource limited setting.

Reconstruction of Lateral Skull Base Defects

Objectives

To compare reconstructive techniques, operative times, duration of hospitalization, and need for subsequent flap revisions between reconstructive approaches to lateral skull base defects.

Study Design

Case series with chart review.

Setting

Tertiary academic referral center.

Subjects

Patients (n = 31) undergoing reconstruction of composite lateral skull base defects from 2002 to 2014.

Methods

Data were analyzed for demographics, tumor characteristics, reconstructive technique, operative time, duration of hospitalization, complications, and outcomes.

Results

Thirty-one patients were identified for inclusion. Lateral temporal bone defects resulted from resection of malignant lesions, including squamous cell carcinoma (n = 25), basal cell carcinoma (n = 2), and other carcinoma (n = 4). Defects were reconstructed with submental flaps (n = 16), pedicled latissimus dorsi flaps (n = 6), and free anterolateral thigh flaps (n = 9). All cases involved neurosurgery, neurotology, and head and neck surgery services. Although time of surgical resection was similar, time saving was noticed with submental reconstruction. Compared with free flaps, submental flap reconstruction was associated with significantly reduced total operative time (mean, 544 vs 683 min; P = .00817) and duration of hospitalization (4.9 vs 9.8 days; P = .02067). Submental flaps were significantly less likely to require revision debulking procedures (mean = 0.6) compared with latissimus dorsi flaps (mean, 1.3; P < .00001) and free flaps (mean, 1.6; P < .00001). There was 100% flap survival.

Conclusion

The musculocutaneous submental flap provides an excellent option for reconstruction of lateral skull base defects given its proximity, reliability, ease of harvest, and exceptional color match. Submental flap reconstruction was associated with reduced operative time, hospitalization duration, and flap revisions.

The submental island flap for reconstruction of temporal bone defects

OBJECTIVE

Untreated cutaneous malignancies involving the lateral aspect of the cranium often invade the temporal bone, necessitating a resection of this site. The reconstruction of the associated complex defect typically requires a reconstructive flap placement to obliterate the resection cavity and provide an aesthetically pleasing restoration. We performed a retrospective case review of 30 patients undergoing temporal bone resection and reconstruction with a submental island flap (SIF), free flap, or temporalis rotation flap. We sought to evaluate the benefit of the submental island flap over the other reconstructive options in terms of cost benefit, patient aesthetic satisfaction, complications, morbidity, and duration of hospitalization.

SETTING

Tertiary referral center.

PATIENTS

Patients who underwent temporal bone resection requiring reconstruction.

INTERVENTION(S)

Therapeutic.

MAIN OUTCOME MEASURE(S)

Main outcome measures included time to functional recovery, patient satisfaction, and hospital stay.

RESULTS

In total, 30 patients were included in this study. Twenty-three patients received a SIF, three underwent a radial forearm free flap, two underwent a temporalis rotation flap, one received a sternocleidomastoid flap, and one received a myocutaneous flap. Average ICU stay after surgery was under 2 days for non-SIF patients. No SIF patients spent time in the ICU nor were there complications reported in this group. Patients who underwent SIF showed a quicker functional recovery, increased satisfaction with appearance of reconstruction, and improved cosmetic results.

CONCLUSIONS

Submental island flap reconstruction is an appealing option for the reconstruction of temporal bone defects. This technique offers decreased length of ICU stays, increased patient satisfaction, and decreased complication rates compared with other reconstructive techniques.

[Submental island flap: a review of the literature]

The submental island flap is a precious tool in reconstructive surgery. It was described by Martin in 1993, inspired by platysma flaps. In our days, we can find many reliable techniques for this procedure. We reviewed the main studies of the literature that described a total of 528 patients. The rate of partial necrosis was 5.1%, complete necrosis 1.7%, and reversible lesions of the marginal mandibular branch of the facial nerve 1.1%. His versatility makes this flap appropriate for the reconstruction of every part of the face: cheeks, nose, forehead, moustache, beard, and hairs. It can also be used de-epidermised with very good results, for the reconstruction of the buccal cavity, the tongue, the roof of the mouth, the larynx, and the proximal part of the esophagus. The SMAP (Submentalis Artery Perforator flap) is an alternative flap that provides even better cosmetic results. The development of indocyanine green and infrared cameras will allow in a close future to decrease the postoperative complications.

Oncologic Safety of the Submental Flap for Reconstruction in Oral Cavity Malignancies

Objectives

To evaluate the oncologic safety of the submental flap regarding potential transposition of involved nodes to the reconstruction site and recognize the submental flap as an excellent option for oral cavity reconstruction.

Study Design

Case series with chart review.

Setting

Tertiary academic referral center.

Subjects and Methods

All patients undergoing reconstruction with submental flaps following the resection of primary and recurrent malignancies of the oral cavity between 2002 and 2012 were reviewed. Analysis included tumor location, staging, reconstructive details, postoperative course, and outcomes.

Results

Fifty patients were identified having undergone submental flap reconstruction of defects following resection for oral cavity malignancies. No patient had identifiable clinical or radiographic level I nodal involvement preoperatively. Patients’ ages ranged from 35 to 88 years (mean, 70 years). American Joint Committee on Cancer staging of patients included stage II (n = 16, 32%), stage III (n = 10, 20%), and stage IVa disease (n = 28, 48%). All patients underwent a level 1A and 1B dissection with removal of the nodal basin and submandibular gland. The prevalence of occult lymph node metastasis involving level 1 was 10%. On follow-up, there were no local recurrences associated with submental flap transposition to the oral cavity. One patient with multifocal oral disease had a tongue recurrence geographically separate from the submental flap reconstruction. There was 100% flap survival.

Conclusions

The submental flap provides a rapid and reliable option for oral cavity defect reconstruction. With appropriate management of the level 1 nodal compartment, oncologic outcomes are not compromised.